Theft Claim Form - TEST SITE Star Insurance Specialists

Insured details

Full details of Insured / Owner

Policy holder

If company, contact name

Policy number

Mobile

Alternative contact

Email

Brokerage

Broker name (if known)

Broker claim reference

What is your street address?

Is the vehicle registered under the same name as the Insured's name above?

Yes
No

Name

Phone

Address

Vehicle details

Search for your vehicle registration

Registration

Vin # if not registered

Year

Make

Model

If your vehicle is financed or leased please name your finance company below:

Finance company here

Finance contact number

Is the vehicle subject to any hire purchase arrangements?

Yes
No

To whome

Phone

Contract/policy number

Address

Repayment amount

Theft details

Keys

How many sets of keys are there?

Who held the keys at the time of theft?

Name

Phone

Address

Where are all vehicle keys now? (we may ask you to produce them if required)

Please give a summary of your movements and activities in the 12 hours prior to the vehicle loss

Police investigation

Do the Police have knowledge of this theft?

Yes
No

Please tell us why not

Did the Police attend the scene of the theft?

Yes
No

Name & number of officer

Email

Police reference number

Address of Police station

Are there any suspects by the police?

Yes
No

Please provide details

Do you have any suspects?

Yes
No

Please provide details

Has anyone witnessted the theft?

Yes
No

Please provide details

Is there any cctv footage available or that can be obtained to help identify the offenders?

Yes
No

Please provide details

Vehicle history

Purchase and sale history

Date of purchase e.g. 20/07/2008

/ /

Purchased from

Purchase price

I consider current value to be

Have you offered the vehicle for sale in the past 12 months?

Yes
No

What was the first asking price?

What was the last asking price?

How long was the vehicle for sale?

If somebody was due to purchase it please provide their name, address and any contact

Name

Telephone number/s

Address

Specifications & modifications

Exterior details:

Colour when stolen (detailed)

Colour changes made by present owner

Details of the wheel assemblies (i.e. colour/identifying features/mags/standard)

Interior details:

Interior trim (i.e. colour/material/type, include seats/door panels and dashboard)

Was the Radio/stereo

Original
Aftermarket
Custom

Make and model

Where fitted in vehicle

How fitted

Speaker location - make/type

Floor mats/carpets

Original
Aftermarket
Custom

Seatbelts

Original
Racing
Custom

Accessories & identifiable contents:

Are there any additional vehicle accessories (i.e. stickers, badges, additional items inside or out?

Yes
No

Please list the accessories

Description

Age of item

Remove

Add accessory

To help us identify the vehicle, please let us know any other contents in vehicle including in the glove compartments/trays/door pockets. Was there any?

Yes
No

Please list identifiable contents

Description

Remove

Add item

General condition & service history

Do you have any details of previous damage that was repaired?

Yes
No

Where was the damage on vehicle?

Who repaired it?

When was it repaired? e.g. 20/07/2008

/ /

Was there any damage on the vehicle at time the vehicle was stolen?

Yes
No

Where was the damage on vehicle?

Service & repair history:

The vehicle is usually serviced by?

Are you able to provide any previous repair / service accounts?

Yes
No

Please attach documentation in the Photos & documents section

Warrant/Certificate of Fitness:

The Warrant/Certificate of Fitness was obtained from?

Date e.g. 20/07/2022

/ /

Expires on e.g. 20/07/2023

/ /

Please describe the condition of the following:

Body (i.e. rust or poor repairs)

Paintwork (i.e. faded or patchy)

Dash top (i.e. cracked)

Did the engine use oil?

Yes
No

How much per month?

Did the vehicle run well?

Yes
No

Please provide details

Declaration questions

You should not disclose any information about offences that can be withheld under the Criminal Records (clean slate) Act 2004
If you answer “YES” to any of the questions above, please provide full details
(Please include dates for any offences/accidents listed)

Photos and documents

Declaration

Pursuant to the Privacy Act 2020

To be completed by the Insured(s) shown and also on behalf of any other person covered by these insurances.

Your insurer is Berkshire Hathaway Specialty Insurance Company

I/We:

Declare to the best of my/our knowledge and belief all information given to Star Insurance Limited (Star) who acts as agent for the insurer and/or any other party(ies) authorised by Star or the insurer to receive information from me in connection with this claim (whether this information is supplied orally or is written) is complete, true and correct and no information relevant to the claim is omitted.
Agree to provide any further information that may be required by Star, the insurer or any other party(ies) authorised by Star or the insurer to receive information and/or to process this claim.
Authorise the disclosure of this information to other parties, including parties with a financial interest, private investigators, crown authorities, advisors, repairers or parties involved in replacing the subject matter of this claim.
Authorise the obtaining personal information about me/us that is in Star and/or the insurer and/or any other party(ies) authorised by Star and/or the insurer to process this claim view as relevant to this claim.
Understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by Star and/or the insurer and/or any other party(ies) authorised by Star and/or the insurer to process this claim.

The information in this claim is complete, true and correct and no information relevant to the claim is omitted

Type your full name here

Start your theft claim here.

Insured details

Full details of Insured / Owner

Vehicle details

Theft details

Police investigation

Vehicle history

Purchase and sale history

Specifications & modifications

General condition & service history

Declaration questions

You should not disclose any information about offences that can be withheld under the Criminal Records (clean slate) Act 2004
If you answer “YES” to any of the questions above, please provide full details
(Please include dates for any offences/accidents listed)

Photos and documents

Caravan contents

Declaration

Pursuant to the Privacy Act 2020

Start your theft claim here.

We aim to make your claim for theft simple and as stress free as we can. To help us, please ensure you complete this form accurately. If you’d prefer to complete your claim at another time, you can save and finish it at your convenience. If you have any questions, you can call us on 0800 250 600.

Insured details

Full details of Insured / Owner

Vehicle details

Theft details

Police investigation

Vehicle history

Purchase and sale history

Specifications & modifications

General condition & service history

Declaration questions

You should not disclose any information about offences that can be withheld under the Criminal Records (clean slate) Act 2004 If you answer “YES” to any of the questions above, please provide full details (Please include dates for any offences/accidents listed)

Photos and documents

Caravan contents

Declaration

Pursuant to the Privacy Act 2020

You should not disclose any information about offences that can be withheld under the Criminal Records (clean slate) Act 2004
If you answer “YES” to any of the questions above, please provide full details
(Please include dates for any offences/accidents listed)